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In Team Training
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Problem representation
Adult male presents with a four-hour history of acute right lower quadrant (RLQ) pain.
Hypothesis generation
Right lower abdominal pain is mainly associated with GI, urological and gynaecological origin. It can also be associated with referred pain. Given you are dealing with a male patient, you can discount gynaecological causes.
Based on the acute nature of his symptoms and his age, a number of conditions are more likely and should be considered first.
Likely diagnosis
- Appendicitis (also critical diagnosis)
- Constipation
- IBD
- IBS
- Pyelonephritis.
Possible diagnosis
- Abdominal wall haematoma
- Diverticulitis
- Hernia
- Kidney stones.
Critical diagnosis
- Appendicitis
- Carcinoma
- Intestinal obstruction
- Perforated ulcer
- Testicular torsion.
Continued information gathering
Initial thoughts on the most likely diagnoses have so far been based on location and age. So you now need to better understand the pain Chris is experiencing – for example, its onset, severity and quality.
Chris confirms that the pain started this morning quite suddenly and describes it as constant, aching and bothersome. You ask him to rate the pain on a scale of 0-10 to try and assess the severity. He rates the pain as a seven. The severity of the pain seems to rule out constipation.
Of the remaining likely diagnoses, appendicitis seems a plausible differential diagnosis given the severity of the pain, which is constant, combined with the right lower quadrant location.
You ask about associated symptoms to help rule out other causes and rule in appendicitis. Chris says he has had no other symptoms but does feel off-colour.
This suggests IBD and IBS are less likely (GI symptoms are common), as too is pyelonephritis, with UTI symptoms being prominent.
Feeling off colour may mean he has systemic symptoms. A temperature check reveals he has a low-grade fever. This symptom would be consistent with appendicitis and pyelonephritis.
Based on the information gathered to date, your suspicion of appendicitis is now stronger even though Chris is older than most people who get it.
